Neuro

In order to protect the airway in a client with a Glasgow Coma Scale score of 3, the nurse collaborates with the health care team to assist with which of the following? 1. Endotracheal intubation 2. Assessment of bowel sounds 3. Monitoring oxygen saturation 4. Questioning the client regarding difficulty breathing

1

An emergency department nurse caring for a client who has been diagnosed with an ischemic stroke that preceded a fall anticipates the need to initially prepare the client for: 1. Administration of t-PA (tissue plasminogen activator). 2. A CT scan (computerized tomography). 3. Full-body x-ray series. 4. Craniotomy.

1. Administration of t-PA (tissue plasminogen activator).

What interventions would be appropriate to reduce the patient's blood pressure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess for pain when measuring blood pressure. 2. Assess for bladder distention. 3. Assess neurologic function with every blood pressure assessment. 4. Administer medication to reduce blood pressure by 15% over 24 hours. 5. Provide antihypertensive medication to reduce pressure to normal levels.

1. Assess for pain when measuring blood pressure. 2. Assess for bladder distention. 3. Assess neurologic function with every blood pressure assessment. 4. Administer medication to reduce blood pressure by 15% over 24 hours

A patient is diagnosed with an intracerebral hemorrhage. What is the most common cause of this disorder? 1. Hypertension 2. Atrial fibrillation 3. Atherosclerosis 4. Hyperinsulinemia

1. Hypertension Feedback: The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis. Intracerebral hemorrhage results from hypertension when the arteries in the brain become brittle and susceptible to cracking, and rupture. Atrial fibrillation increases the risk of the development of an ischemic cerebrovascular accident. Atherosclerosis is the cause of hypertension, which can lead to intracranial hemorrhage. Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension, which may eventually lead to an intracranial hemorrhage. However, this is not a primary cause.

A patient is diagnosed with meningitis that developed after experiencing otitis media. What will the nurse most likely assess in this patient? Select all that apply. 1.Fever 2. Stiff neck 3. Confusion 4. Photophobia 5. Palpitations

1.Fever 2. Stiff neck 3. Confusion 4. Photophobia

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse? 1. Treat the patient's pain. 2. Assess the patient's airway, breathing, and circulation. 3. Obtain a complete history from the patient. 4. Triage the patient with the other ED patients.

2

A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is: 1. An anticonvulsant 2. A steroid 3. A barbiturate 4. A pain medication

2. A steroid Feedback: Steroids are currently recommended as adjunctive treatment of bacterial meningitis. Dexamethasone is believed to interrupt the neurotoxic effects resulting from the lysis of bacteria during the first days of antibiotic use. When steroids are given, they should be administered prior to or during the administration of antibiotics on the first 2 days of therapy.

A patient arrives in the emergency department with a flail chest after a motor vehicle accident (MVA) in which the patient's chest hit the steering wheel. The nurse realizes this injury is due to: 1. Blunt trauma from internal forces caused by acceleration 2. Blunt trauma from external forces caused by deceleration 3. Penetrating trauma from external forces caused by deceleration 4. Penetrating trauma from internal forces caused by acceleration

2. Blunt trauma from external forces caused by deceleration

A patient's mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to: 1. Increased intracranial pressure 2. Hypoxic cerebral tissue 3. Increased urine output 4. Bradycardia

2. Hypoxic cerebral tissue

The nurse notes that a client has an elevated cholesterol level. Which health problem is this client at risk for developing? 1. Osteoarthritis 2. Ischemic stroke 3. Hemorrhagic stroke 4. Traumatic brain injury

2. Ischemic stroke

The nurse suspects that a client with a brain tumor is experiencing increasing intracranial pressure. What findings did the nurse use to make this clinical determination? Select all that apply. 1. Extreme thirst 2. Projectile vomiting 3. Weak left hand grasp 4. Unresponsive right pupil 5. Blood pressure 180/48 mm Hg

2. Projectile vomiting 3. Weak left hand grasp 4. Unresponsive right pupil 5. Blood pressure 180/48 mm Hg Feedback: Vomiting that is due to increased ICP typically occurs without nausea, is unexpected, is projectile, and is due to direct pressure on vagal motor centers located in the fourth ventricle in the medulla. A change in motor function, changes in pupillary function, and a widening pulse pressure are indicators of increasing intracranial pressure.

The nurse is caring for a patient who is comatose after a traumatic brain injury. Which of the following would be important for the nurse to include when planning for this patient's nutritional needs? 1. limit protein intake to encourage the body to utilize circulating blood glucose 2. ensure adequate protein intake to maintain a positive nitrogen balance 3. plan to implement hyperalimentation as soon as possible 4. provide adequate calories in the form of carbohydrates and fats

2. ensure adequate protein intake to maintain a positive nitrogen balance

The nurse is caring for a client with a medical diagnosis of increased intracranial pressure. Which IV fluid order should the nurse accept without questioning? 1. Normal saline at 125 mL/hour. 2. Dextrose 5% and water at 80 mL/hour. 3. Dextrose 5% and 0.45% NaCl at 75 mL/hour. 4. Normal saline 0.45% at 200 mL/hour.

3. Dextrose 5% and 0.45% NaCl at 75 mL/hour.

A 13-year-old client has been diagnosed with meningitis caused by Haemophilus influenzae type B. What drug is commonly prescribed to prevent this disease from occurring in individuals who had close contact with the client prior to the illness? 1. Metronidazole (Flagyl) 2. Daptomycin (Cubicin) 3. Rifampin (Rifadin) 4. Ciprofloxacin (Cipro)

3. Rifampin (Rifadin) Feedback: : Rifampin is the drug of choice for prophylaxis of persons who have come in contact with clients with Haemophilus influenzae type B. Metronidazole is a miscellaneous antibacterial that is effective against both bacteria and multicellular parasites. It is the drug of choice for trichomoniasis, giardiasis, and amebiasis. Daptomycin is a miscellaneous antibacterial that is indicated for the treatment of complicated skin infections such as those caused by MRSA and VRSE. Ciprofloxacin is used for the treatment and prevention of

The nurse explains that a patient who has been determined to have had a complete stroke as a result of a ruptured vessel in the left hemisphere would be classified as: 1. ischemic, embolic. 2. hemorrhagic, subarachnoid. 3. hemorrhagic, intracerebral. 4. ischemic, thrombotic.

3. hemorrhagic, intracerebral.

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. The nurse realizes that what will most likely be implemented for this patient? 1. Prophylactic hypothermia treatment 2. High-dose barbiturate therapy 3. Intubation 4. Prophylactic anticonvulsant therapy

4 Rationale 1: Prophylactic hypothermia treatment is not recommended for routine use at this time. Rationale 2: High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures. Rationale 3: Most patients with a traumatic brain injury will be intubated. Rationale 4: Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury.

A patient is being admitted after sustaining a head injury from an acceleration/deceleration motor vehicle accident. The type of injury that this patient most likely sustained would be: 1. Skull fracture 2. Penetrating 3. Concussion 4. Coup-countercoup

4. Coup-countercoup

The nurse is caring for a patient who experienced an ischemic stroke 8 hours ago. The nurse would expect an order to administer which medications designed to prevent further obstruction of vascular cerebral blood flow? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Intravenous dopamine 2. Intravenous mannitol 3. Subcutaneous insulin 4. Intravenous heparin 5. Subcutaneous low-molecular-weight heparin

4. Intravenous heparin 5. Subcutaneous low-molecular-weight heparin

A patient with a brain tumor is having a diagnostic test to help determine response to therapy. This patient is most likely having a(n): 1. CT scan 2. PET scan 3. Angiogram 4. MRI

4. MRI

A patient with an ischemic stroke has an oxygen saturation of 88%. What should be done to help this patient? 1. Position the patient on one side. 2. Elevate the head of the bed. 3. Provide low-dose oxygen. 4. Provide high-dose oxygen.

4. Provide high-dose oxygen.

The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and records the LOC score as 6 . What does an LOC score of 6 in a client indicate? A) Comatose B) Somnolence C) Stupor D) Normal

A

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance

A) Cardiac and respiratory status

A client with aphasia presents to the emergency room with a suspected brain attack. What assessment data would lead the nurse to suspect this client has had a thrombotic stroke? A. Two episodes of speech difficulties in the last month B. A sudden loss of motor coordination C. Recent seizure activity D. Nuchal rigidity

A. Two episodes of speech difficulties in the last month

A nurse assesses a postoperative patient's level of consciousness and documents the following: the patient opens eyes spontaneously when someone approaches, accurately responds to instructions, converses, and is oriented to time, place, and person. What number would this patient receive on the Glasgow Coma Scale? A) 20 B) 15 C) 10 D) 5

B

A patient with traumatic brain injury is being assessed. This patient demonstrates gross defects in visual acuity on reading a Snellen eye chart. Which cranial nerve is most likely damaged? A) Cranial nerve I B) Cranial nerve II C) Cranial nerve III D) Cranial nerve IV

B) Cranial nerve II

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. What goal is a priority for this patient? A) Maintain adequate urine output. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety. D) Relieve sensory deprivation.

B) Maintain and improve cerebral tissue perfusion.

Which alteration when manifested in a client with atrial fibrillation should alert the nurse to the possibility of an embolic stroke? A. A pulse deficit B. Speech alterations C. Distended neck veins D. Hyperresponsive deep tendon reflexes

B. Speech alterations

The nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA). On which understanding should a nurse base teaching? a. TIAs are not serious, and the patient should have no further problems. b. A TIA is predictive that the patient will have a heart attack within 1 year. c. A TIA is a forewarning that the patient is at risk for a cerebrovascular accident (stroke). d. A TIA is a medical emergency that requires immediate surgical intervention.

C Feedback: About a third of patients who experience a TIA will have a stroke in the future. Urgent evaluation of TIA is essential in order to decrease the risk of stroke. There are no data related to myocardial infarction (MI) prediction. It is not a surgical problem.

The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected. B) Take ibuprofen for complaints of a serious headache. C) Take antihypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.

C) Take antihypertensive medication as ordered.

A patient with a traumatic brain injury is at high risk for a secondary brain injury. What is the best nursing explanation of a secondary brain injury? A) Result of a repeated assault incident B) From a penetrating gunshot wound C) Trauma inflicted by another person D) Cerebral edema and ischemia

D) Cerebral edema and ischemia

After a traumatic brain injury, a patient is found to be positioned with arms extended and hands clenched. This position is indicative of: A) Spinal cord lesion. B) Frontal lobe lesion. C) Decorticate posturing. D) Decerebrate posturing.

D) Decerebrate posturing.

A nurse is caring for a patient with an arteriovenous malformation (AVM). What symptom is the nurse most likely to observe in this patient? A) Seizure B) Headache C) Intracranial pressure D) Hemorrhage

D) Hemorrhage

The client has a history of recurrent transient ischemic attack (TIA). Based upon this history, the nurse is most concerned about the client's potential to develop which of the following? A) Gangrene B) Renal failure C) Myocardial infarction D) Stroke

D) Stroke

A patient complained of slurred speech, weakness in the right side, and a bit of confusion lasting for only ten minutes. She is being admitted for a neurological work-up. In assessing her symptoms, she most likely was experiencing a/an A) incomplete stroke that is still progressing. B) subdural hematoma. C) intracerebral bleed. D) transient ischemic attack.

D) transient ischemic attack.

The mechanism of head injury occurring in a fall is usually A) an acceleration injury. B) a deceleration injury. C) coup-contrecoup injury. D) none of the above.

B) a deceleration injury.

The nurse is planning care for a client with increased intracranial pressure. Which intervention should the nurse add to this client's care plan? 1. Keep the head of the bed flat 2. Provide with opioid analgesic for pain 3. Administer hypertonic saline as prescribed 4. Hyperventilate with 100% oxygen every 2 hours

3. Administer hypertonic saline as prescribed

A patient is demonstrating neurologic changes consistent with increasing intracranial pressure. For which primary causes of this pressure increase will the nurse assess at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cerebral hemorrhage 2. Ischemic stroke 3. Airway obstruction 4. Drop in blood pressure 5. Electrolyte imbalance

1. Cerebral hemorrhage 2. Ischemic stroke

The nurse is caring for a patient with transient ischemic attack (TIA). Which medication should the nurse expect to be prescribed for this patient? 1. antiplatelet agents 2. fibrinolytic therapy 3. anticoagulant therapy 4. Corticosteroids

1 Feedback: Antiplatelet agents are often used to prevent TIAs and strokes in patients who have had previous strokes. These drugs prevent clot formation and blood vessel occlusion. They include aspirin, clopidogrel (Plavix), dipyridamole (Persantine), and ticlopidine (Ticlid). Fibrinolytic therapy is used to treat thrombotic stroke. Anticoagulant therapy is often ordered to treat ischemic stroke. Corticosteroids are used to treat cerebral edema.

A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects cerebral herniation the most appropriate intervention would be to: 1. Briefly hyperventilate the patient. 2. Take measures to increase intracranial pressures by Trendelenburg positioning. 3. Prepare for emergency surgical repair. 4. Contact the family to come say their last words with the patient.

1. Briefly hyperventilate the patient. Feedback: Rationale 1. Hyperventilating the patient lowers the ICP by lowering the PaCO2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow. Rationale 2: This position places the patient at greater risk of permanent damage from decreased cerebral blood flow. Rationale 3: Emergency surgery might be needed but hyperventilating the patient will temporarily allow more time for informed decision making. Rationale 4: Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first.

Which of the following observations by the nurse are representative of the symptomology of an epidural hematoma (EDH)? Select all that apply. 1. History of unconsciousness immediately after trauma 2. Dilated pupil on the same side as the injury 3. Rapid deterioration of level of consciousness 4. Period of lucidity prior to onset of symptoms 5. Muscle weakness on the side opposite the head injury

1. History of unconsciousness immediately after trauma 2. Dilated pupil on the same side as the injury 3. Rapid deterioration of level of consciousness 4. Period of lucidity prior to onset of symptoms ANS: 1,2,3,4 Feedback: : (1) History of unconsciousness immediately after trauma. Classic clinical presentation of EDH is characterized by an immediate post-traumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours. (2) Dilated pupil on the same side as the injury. Possible signs and symptoms include an enlarging pupil on the same side of the injury (ipsilateral). (3) Rapid deterioration of level of consciousness. A rapid deterioration in level of consciousness may follow. Period of lucidity prior to onset of symptoms. Classic clinical presentation of EDH is characterized by an immediate post-traumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours. (4) Muscle weakness on the side opposite the head injury. Hemiparesis (muscle weakness) of the contralateral arm and leg (opposite side from the injury) may be present with an acute subdural hematoma.

A patient with a traumatic brain injury is diagnosed with an acute subdural hematoma. What would the nurse be more likely to assess in this patient than in one who had experienced a chronic subdural hematoma? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Loss of consciousness 2. Hemiparesis 3. Dysphagia 4. Confusion 5. Headache

1. Loss of consciousness 2. Hemiparesis 3. Dysphagia Rationale: Confusion and headache are manifestations of chronic subdural hematoma.

A client with increased intracranial pressure (ICP) is being repositioned. The nurse performs this intervention incorporating which of the following? Select all that apply. 1. Manage the repositioning with slow, smooth, and gentle movement. 2. Inform the client regarding what is going to occur during the intervention. 3. Elevate the head of the bed to 30 degrees. 4. Accompany each repositioning with passive range-of-motion exercises. 5. Reposition the client every 1 to 2 hours.

1. Manage the repositioning with slow, smooth, and gentle movement. 2. Inform the client regarding what is going to occur during the intervention. 3. Elevate the head of the bed to 30 degrees. Feedback: Manage the repositioning with slow, smooth, and gentle movement. It is especially important that clients with increased ICP should be repositioned slowly and with smooth, gentle movements, because rapid changes can cause the pressure to increase. Inform the client regarding what is going to occur during the intervention. Clients should always be informed about what is going to occur. Elevate the head of the bed to 30 degrees. The head of the bed should be elevated. The degree depends on the reaction of the client to the position; 30 degrees is usually appropriate, but this can vary by the client. Accompany each repositioning with passive range-of-motion exercises. Position changes should be done less frequently for clients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary posturing, which also causes increased ICP. Reposition the client every 1 to 2 hours. Position changes should be done less frequently for clients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary posturing, which also causes increased ICP.

A patient with increased intracranial pressure after a traumatic brain injury is demonstrating an irregular breathing pattern, a slower heart rate, and a rising systolic blood pressure. Which of the following should the nurse suspect is occurring with this patient? 1.Brain herniation 2. Stroke in evolution 3. Myocardial infarction 4. Acute renal failure

1.Brain herniation Feedback: When herniation is occurring, the nurse will see drastic deterioration patterns in the patient's neurologic status and vital signs. The classic vital sign changes are called Cushing's triad, which consists of bradycardia, severe hypertension with a widened pulse pressure, and irregular breathing. These same symptoms may or may not be assessed if the patient is experiencing a stroke in evolution. These are not necessarily signs of a myocardial infarction. There is not enough information to determine if the patient is demonstrating acute renal failure

A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. The patient tells the nurse that these symptoms have been getting worse since hitting his head on a surf board while on vacation several weeks prior. Which of the following should the nurse suspect is occurring in this patient? 1. Subacute subdural hematoma 2. Chronic subdural hematoma 3. Acute subdural hematoma 4. Epidural hematoma

2. Chronic subdural hematoma Feedback: There are three categories of subdural hematoma, based on time of onset of symptoms. An acute subdural hematoma occurs less than 48 hours from injury; a subacute occurs 48 hours to 2 weeks from injury, and chronic hematoma develops greater than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse should suspect a chronic subdural hematoma. With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness.

Diagnostic testing has revealed that the patient has an arteriovenous malformation (AVM). Surgical treatment is scheduled for tomorrow. Which critical assessment findings should the nurse report to the surgeon? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Headache unchanged since admission 2. Seizure 3. A period of sudden clarity after previously disturbed thought processing 4. Increased difficulty in talking 5. Sudden decrease in level of consciousness

2. Seizure 4. Increased difficulty in talking 5. Sudden decrease in level of consciousness

The assessment indicating that mannitol therapy for cerebral edema is effective in a patient with increased intracranial pressure (ICP) is: 1. increased blood pressure. 2. increased urinary output. 3. decreased pulse. 4. widening pulse pressure.

2. increased urinary output. Feedback: Mannitol is a hyperosmolar diuretic that draws fluid from brain tissue into the bloodstream, which is then excreted by the kidneys. Decreasing pulse and widening pulse pressure indicate increased ICP.

A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of: 1. A cerebral spinal fluid leak 2. A subdural hematoma 3. An epidural hematoma 4. A subarachnoid hemorrhage

3. An epidural hematoma Feedback: Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval and then a sudden re-loss of consciousness with rapid deterioration in neurologic status.

The nurse is assessing a patient with a meningioma. The nurse realizes that this patient will have: 1. A hearing disorder 2. A life expectancy of about 10 months 3. An excellent prognosis if the tumor is totally removed 4. Metastasis to other body organs

3. An excellent prognosis if the tumor is totally removed Feedback: Rationale 1: Other common benign brain tumors arise from nerve sheaths such as acoustic neuromas, which can lead to a hearing loss. Rationale 2: Meningiomas are usually benign and do not affect life expectancy. Rationale 3: The most common benign brain tumors arise from the meninges and are called meningiomas. They are usually well circumscribed, may be attached to the dura, and are associated with an excellent prognosis when gross-total resection is possible. Rationale 4: Meningiomas are encapsulated and benign so therefore do not metastasize to other organs.

The nurse is preparing to administer a medication to a patient to decrease the cerebral edema caused by a brain tumor. This medication is most likely a(n): 1. Antiseizure medication 2. Pain medication 3. Glucocorticoid 4. Antispasmodic

3. Glucocorticoid

The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which of the following assessment findings would be considered an emergency? 1. Weak hand grasps bilaterally 2. Fine crackles auscultated bilateral lung bases 3. Urine output 36 cc per hour 4. Fixed and dilated pupil on the side of the injury

4. Fixed and dilated pupil on the side of the injury Feedback:Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation. Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Fine crackles auscultated bilateral lung bases might be due to immobility and not necessarily a change in the patient's neurological status. Urine output of 36 cc per hour would be a normal urine output requiring no intervention

A client with increased intracranial pressure caused by a traumatic brain injury is in a coma. What approach should the nurse use to assess this client's impaired consciousness? 1. Glasgow Coma Scale 2. Determine degree of brainstem reflexes 3. Assess pupillary response to light and accommodation 4. Use the Un-Responsiveness (FOUR) Score Coma Scale

4. Use the Un-Responsiveness (FOUR) Score Coma Scale

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? A) Unilateral ptosis B) Respiratory distress C) Severe headache D) Nausea and vomiting

A Feedback: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.

The patient has scored a 7 on the Glasgow Coma Scale which is used to assess the head injured patient. The nurse recognizes that the patient: A) Is generally interpreted as comatose B) Is within normal range but unstable C) Needs emergency attention D) Has scored as a normal individual

A Feedback: The Glasgow Coma Scale (possible scores range from 3 to 15) is a tool for assessing a patient's response to stimuli. A score of 10 or less indicates a need for emergency attention; a score of 7 or less is generally interpreted as coma

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? A) Epidural B) Subdural C) Intracerebral D) Cerebral

B) Subdural Feedback: A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

A patient is admitted to the Neuro ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? A) MRI B) PET scan C) X-ray D) Ultrasound

A) MRI

After a large ischemic stroke, a possible complication is cerebral edema. What would nursing interventions during this period include? A) Positioning to avoid hypoxia B) Maintaining PaCO2 within the range of 20 to 25 mm Hg C) Administering a sodium-sparing diuretic D) Maintaining the patient in the supine position

A) Positioning to avoid hypoxia

A patient has been admitted to the Neuro ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. What is an important part of the initial assessment on this patient? A) The gag reflex B) Ability to chew C) Sensory perception D) Corneal reflex

A) The gag reflex

A patient presents to the emergency department due to head trauma related to a motorcycle accident. On physical examination, you note clear, serous discharge from the ear. This is commonly a sign of: A. Basilar skull fracture B. Injury of the auricle C. Otitis discharge D. Tympanic membrane perforation

A. Basilar skull fracture Feedback: In cases of head trauma, there are signs of skull fracture. These signs include cerebrospinal fluid otorrhea, rhinorrhea, and raccoon eyes.

A patient with a traumatic brain injury is given IV phenytoin to prevent seizures. Three days after the drug is started, the patient develops a red, vesicular rash on her trunk. What is the most appropriate collaborative intervention? A) Administer an antihistamine. B) Discontinue phenytoin. C) Evaluate for contact dermatitis. D) Place in contact isolation.

B) Discontinue phenytoin.

You are caring for a patient recovering from an ischemic stroke. You know that it is important to monitor for potential complications. What are the potential complications after an ischemic stroke? A) Hypernatremia B) Pneumonia C) Decreased ICP D) Hyperoxygenation

B) Pneumonia

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A) Providing frequent small meals rather than three larger meals B) Teaching the patient to perform deep breathing and coughing exercises C) Keeping a urinary catheter in situ for the full duration of recovery D) Limiting intake of insoluble fiber

B) Teaching the patient to perform deep breathing and coughing exercises

The pathophysiology of an ischemic stroke includes the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration is made 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order. A) 635241 B) 352416 C) 236145 D) 162534

C) 236145

A patient admitted to the neurological intensive care unit with a brain stem herniation is exhibiting an altered level of consciousness. The nurse has determined that the patient's mean arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse would be correct in determining the cerebral perfusion pressure (CPP) as which of the following values? A) Normal B) High C) Low D) Compensating

C) Low Feedback: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion.

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient? A) Maintaining the patient's functional independence B) Providing health education C) Monitoring neurologic status closely D) Promoting mobility

C) Monitoring neurologic status closely Feedback: Vigilant neurologic monitoring is a key aspect of caring for a patient who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.

The patient has had a stroke or brain attack, believed to be ischemic in nature. The causes of an ischemic stroke are least likely to include which of the following? A) Thrombus of a cerebral artery B) Embolus of a cerebral artery C) Ruptured cerebral aneurysm D) Cerebrovascular obstruction

C) Ruptured cerebral aneurysm

A client has been admitted to the hospital after having a brain attack. What predisposing factor in this client's history places this client at risk for embolic stroke? A. A history of seizures B. A history of psychotropic drug use C. A history of atrial fibrillation D. A history of cerebral aneurysm

C. A history of atrial fibrillation

A 35-year-old client is admitted with a possible brain attack. What data from the client's history places the client at risk for this problem? A. Recent viral infection B. Seizure disorder C. Cocaine abuse D. Sleep apnea

C. Cocaine abuse

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? A) "I sense that you are happy it was not a stroke." B) "People who experience a TIA will develop a stroke." C) "TIA symptoms are short lived and resolve within 24 hours." D) "TIA is a warning sign. Let's talk about lowering your risks."

D Feedback: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short lived, but this is a factual statement that does not provide additional information to the client

A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke? a. Two episodes of speech difficulties in the last month b. Sudden loss of motor coordination c. A grand mal seizure 2 months ago d. Chest pain and nuchal rigidity

a Feedback: Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs. The other manifestations are not related to a thrombotic stroke.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

a Feedback: tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission b. Wash hands thoroughly before leaving the room c. Scrub the hub of all central line ports prior to use d. Dispose of all bloody dressings in biohazard bags

a. Implement droplet precautions upon admission Feedback: Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. USE SURGICAL MASK! Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

The nurse is planning care for a patient with an intracerebral hemorrhage. What should be identified as a goal for this patient? a. Maintain blood pressure below 120/80 mm Hg b. Resume activities of daily living as soon as possible c. Expect to experience transient numbness and tingling d. Receive thrombolytic medication therapy within an hour

a. Maintain blood pressure below 120/80 mm Hg

The patient had a carotid ultrasound that showed a 40% obstruction following a transient ischemic attack (TIA). The nurse anticipates that the treatment will consist of: (Select all that apply.) a. diet modification. b. lifestyle alteration. c. aspirin for antiplatelet aggregation. d. daily doses of nitrates. e. endarterectomy.

a. diet modification. b. lifestyle alteration. c. aspirin for antiplatelet aggregation.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first? a. Patient with a transient ischemic attack (TIA) returning from carotid duplex studies b. Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram c. Patient with a seizure disorder who has just completed an electroencephalogram (EEG) d. Patient prepared for a lumbar puncture whose health care provider is waiting for assistance

b Feedback: Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse, blood pressure, and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority.

The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis? a. "This is the worst type of brain tumor, and surgery is not an option." b. "My tumor can be removed, but I can still have damage because of pressure in my brain." c. "Even after the surgery, I will need chemotherapy to decrease the spread of the tumor." d. "Radiation is never used on brain tumors because of possible nerve damage."

b. "My tumor can be removed, but I can still have damage because of pressure in my brain." Feedback: Feedback: Meningiomas arise from the coverings of the brain (the meninges) and are the most common type of benign tumor. This tumor is encapsulated, globular, and well demarcated, and causes compression and displacement of nearby brain tissue. Although complete removal of the tumor is possible, it tends to recur and causes irreversible damage to the brain. The tumor is not treated by chemotherapy or radiation.

A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA). What should the nurse include when assisting in the teaching about this health problem? a. "You had a small hemorrhage in your brain." b. "Your brain was temporarily deprived of oxygen." c. "The neurons in your brain are tangled, so messages get mixed up." d. "You have a vessel that is occluded, blocking the blood supply to your brain."

b. "Your brain was temporarily deprived of oxygen."

Thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) is now recommended for the management of ischemic stroke if administration can be instituted within how many hours of onset of stroke symptoms? a. 1 b. 4 c. 6 d. 10

b. 4

Which area of the brain is affected in a patient who has right-sided weakness and aphasia due to a transient ischemic attack (TIA)? a. Right hemisphere b. Left hemisphere c. Occipital lobe d. Medulla

b. Left hemisphere

Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study? a. Magnetic resonance imaging c. Contrast computed tomography b. Noncontrast computed tomography d. Lumbar puncture

b. Noncontrast computed tomography

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

b. Report the BP and ICP to the health care provider. Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] - diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

Early signs of increased intracranial pressure (ICP) include headache, confusion, vomiting and which of the following? a. brain herniation c. periods of apnea b. decreased level of consciousness d. Hyperventilation

b. decreased level of consciousness

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

c. Explain that the aspirin is ordered to decrease stroke risk.

The nurse is caring for a patient with a traumatic brain injury. Which of the following assessment findings alerts the nurse to possible diabetes insipidus? a. Headache b. Elevated blood glucose c. Frequent urination d. Confusion

c. Frequent urination

The nurse is providing care for a patient who suffered an ischemic stroke and now requires respiratory support with mechanical ventilation. The nurse recognizes that the stroke most likely occurred in which part of the brain? a. Cerebrum b. Hypothalamus c. Medulla d. Cerebellum

c. Medulla

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Inracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 128 beats/minute

c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

c. Risk for acquiring an infection

Mr. Stinson is a 34-year-old patient who presents to the emergency department after an auto accident. On examination, you note raccoon eyes and a positive Battle sign. Raccoon eyes and the Battle sign are associated with: a. multisystem trauma b. orbital fractures c. basilar skull fractures d. subdural hematoma

c. basilar skull fractures Feedback: Raccoon eyes (bruising around the eyes) and the Battle sign (bruising behind the ears) both indicate a basilar skull fracture. Symptoms of orbital fractures are swelling of the eyelid, bruising of the eye, pain in the eye, double vision, and decreased movement of the affected eye. Signs and symptoms of a subdural hematoma are loss of consciousness after the original injury, steady or fluctuating headache, weakness, numbness or inability to speak, slurred speech, nausea, vomiting, lethargy, and seizures.

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg

A client has received thrombolytic therapy for treatment of an ischemic stroke. Which intervention takes priority? a. Assessing nutritional status and planning feeding b. Consulting with the interdisciplinary stroke team c. Providing client and family education d. Stringent blood pressure control

d. Stringent blood pressure control

Brief episodes of neurological dysfunction caused by temporary impairment of blood flow to the brain that last from a few seconds to 24 hours are called: a. aneurysms b. agnosia c. reversible ischemic neurological deficits d. transient ischemic attacks

d. transient ischemic attacks A transient ischemic attack (TIA), a temporary impairment of cerebral blood flow, often precedes a cerebrovascular accident (CVA).